Download Physical Activity in the Prevention and Management of High Blood

Hellenic J Cardiol 2009; 50: 52-59
Review Article
Physical Activity in the Prevention and
Management of High Blood Pressure
PETER F. KOKKINOS1,2, ANGELIKI GIANNELOU1, ATHANASIOS MANOLIS3, ANDREAS PITTARAS1,4
1
Cardiology Department, Veterans Affairs Medical Center, Washington DC, 2Georgetown University School of
Medicine, Washington, DC, USA; 3Cardiology Department, Asklepeion General Hospital, Athens, 4Mediton,
Galatsi, Athens, Greece
Key words:
Hypertension,
physical activity.
Manuscript received:
July 16, 2008;
Accepted:
November 27, 2008.
Address:
Peter F. Kokkinos
Veterans Affairs
Medical Center
Cardiology Department
50 Irving Steet NW
Washington DC 20422
USA
e-mail:
[email protected]
H
ypertension was not recognized as
a menace to health until the latter
part of the last century. Even until
the sixties the prevailing belief among physicians was that a rise in blood pressure
(BP) was an important and essential compensatory mechanism (thus essential blood
pressure) to maintain adequate perfusion
as an individual advanced in age. Based on
that, the use of drugs to lower BP was scoffed at as “treatment of the manometer rather
than of the patient”.1 In the mid 1960s and
early 1970s Dr. Edward Freis and the Veterans Administration study group proved
conclusively that treatment of hypertension
reduces strokes and cardiovascular complications.2-7
Hypertension is now a well established,
major cardiovascular risk factor.8-12 The relationship is direct, strong, continuous,
graded, consistent and independent.12 Mortality and morbidity double for every 20
mmHg increase in systolic BP above 115
mmHg and for every 10 mmHg increase in
diastolic BP above 75 mmHg.13
The World Health Organization
(WHO) reports that the number of people
with hypertension worldwide is estimated to
be as many as 1 billion, with 7.1 million
deaths per year attributable to hypertension.14 The prevalence of hypertension increases with age. A higher percentage of
men have high BP up to the age of 45, while
52 ñ HJC (Hellenic Journal of Cardiology)
women overtake men after 54 years of
age.15 For an individual with normal BP at
the age of 55 years, the risk of developing
hypertension during the remainder of his or
her life is estimated to be 90%.16
It is also broadly accepted that even
small reductions in an abnormally elevated
BP result in a decrease of death from heart
disease and stroke. For example, a 5 mmHg
reduction in diastolic BP over a period of
five years was associated with at least 34%
less stroke and at least 21% less coronary
heart disease (CHD). Reductions of 7.5
mmHg and 10 mmHg are associated with a
46% and 56% decrease in the incidence of
stroke and a 29% and 37% decrease in the
incidence of CHD, respectively.8
An overwhelming number of epidemiological and interventional exercise studies provide unequivocal support that increased physical activity, of adequate duration, intensity and volume, lowers BP
significantly, alone or as an adjunct to pharmacological therapy.17 The purpose of this
review is to assess the efficacy and safety
of exercise in the management of high BP
and its consequences.
Epidemiological and interventional studies
Epidemiological studies that assessed physical activity by a questionnaire, or more
objectively by a treadmill test, suggested
Physical Activity and Hypertension
that fitness levels are inversely associated with BP.18-22
Middle-aged women who were classified as having
moderate and high-fitness, based on their peak exercise time during a treadmill test, had significantly lower diastolic BP (5 and 7 mmHg, respectively) when
compared to women of low fitness level.22 In addition,
cross-sectional and large-scale longitudinal population studies reported that the relative risk for developing hypertension in sedentary men and women with
normal BP at rest is approximately 35% to 70% higher when compared to their physically active peers.23-25
Interventional studies confirmed the epidemiological findings. In a recent review, we reported the
results of well controlled exercise interventional studies for BP control (Table 1). The average exercise-related BP reduction in these studies was 10.5 mmHg
for systolic and 7.6 mmHg for diastolic BP. In the
control group, the average reduction was only 3.8
mmHg and 1.3 mmHg for systolic and diastolic BP,
respectively.17 Similar findings were reported by a recent meta-analysis of randomized controlled trials, involving 72 trials, 105 study groups, and 3936 hypertensive participants. The average exercise-related reduction in resting BP was 6.9 mmHg and 4.9 mmHg
for systolic and diastolic BP, respectively.26
Ambulatory blood pressure monitoring
The changes in BP over a 24-hour period as a result
of exercise training have not been studied extensively.
The few studies that utilized ambulatory BP monitoring reported favorable findings, but a substantially
smaller effect than that reported by the studies assess-
ing resting BP.27-34 However, the small number of participants, the lack of a control group and the different
mode of BP measurement make the interpretation of
the findings difficult.
In the HARVEST trial, where the ambulatory
pressure was recorded in a relatively large population
(n=592) of young stage 1 hypertensive males, the investigators reported that those who engaged in physical activity at least once a week during the previous two
months exhibited lower 24-hour and daytime diastolic
BP by about 3 mmHg compared to the inactive group.19
However, authorities agree that significant changes in
BP are likely to occur when exercising most days of the
week.33 Thus, the exercise-related reduction in BP reported by the HARVEST trial is likely to be attenuated
by the inclusion of those who exercised only once a
week. Based on the limited data on ambulatory BP,
the American College of Sports Medicine concluded
that the average reduction in daytime BP was about
3/3.2 mmHg.33
However, recent epidemiological evidence from
a relatively large study suggests that the magnitude
of daytime BP reduction is substantially higher that
that reported by the aforementioned studies. In over
600 men and women, we reported that the daytime
BP in high and moderate-fitness individuals was 8/4
mmHg lower in men and 9/5 mmHg lower in women,
when compared to the BP of low-fitness individuals. 36 The difference in BP between the low and
high-fitness individuals is similar in magnitude to the
changes reported by interventional studies.17,37 Similar reductions were observed in nighttime and 24hour BP.
Table 1. Summary of findings from select exercise studies involving hypertensive individuals.
Investigators
Blumenthal et al30
Cononie et al48
Higashi et al73
Kokkinos et al43
Matsusaki et al38
Motoyama et al39
Seals et al27
Seals et al61
Somers et al28
Zanettini et al29
Mean age
Exercise intensity
(% of maximum heart rate)
45
70-79
52
57
47
68-84
>49
50-74
–
70-85
70
50-85
Low
60-80
60 & 85
Low
50
50
–
70-85
BP reduction
Systolic
Diastolic
8
10
13
7
9
15
10
10
9.7
15
6
9
4
5
6
9
7
8
6.8
11.5
BP – blood pressure.
(Hellenic Journal of Cardiology) HJC ñ 53
P.F. Kokkinos et al
Optimal exercise intensity for blood pressure reduction
The efficacy of physical activity in the reduction of elevated BP is no longer in question; the challenge now is
to verify the amount and the frequency of exercise that
will produce the maximum health benefits at a relative
low risk for injury. In this regard, low-to-moderate intensity exercise (approximately 60% to 85% of age-predicted maximum heart rate) is more effective in lowering BP when compared to higher intensities.35 In studies designed to compare the effects of different exercise
intensities, low to moderate intensity exercises were
more efficacious in lowering BP than exercise of relatively higher intensities.38-41 Support for this is also provided by a large epidemiological study, where the daytime, nighttime and 24-hour BP in the high-fitness
group was similar to that of the moderate-fitness individuals.36 These findings suggest that the antihypertensive effect of exercise occurs at a moderate level of
physical activity, without significant additional changes
beyond this level. This is clinically significant, because
this level of fitness can be attained by 30-40 minutes of
brisk walking, most days of the week. Such exercise intensity and volume is within the capacity of most middle
aged and older individuals.36
The findings of the Trial of Hypertension Prevention also suggest that moderate intensity physical activity (3.0-6.0 METs) for at least 2-3 days a week is an
appropriate recommendation for the general public
for the prevention of primary hypertension.42
Severe hypertension and exercise
The management of patients with stage 2 hypertension or higher is challenging. It often requires a combination of medication that increases the likelihood
of side effects. The incidence of other co-morbidities
is also high and interferes with the patients’ ability to
exercise. For these reasons, physicians are more concerned about prescribing exercise in patients with
stage 2 hypertension. Regarding the role of physical
activity in the management of this population, two
questions need to be addressed: 1) is exercise safe for
individuals with stage 2 hypertension? 2) is exercise
effective in lowering BP in these individuals?
We examined the effects of moderately intense exercise on BP in patients with stage 2 hypertension.43
After 16 weeks of moderate-intensity exercise training, resting systolic BP was lowered by 7 mmHg and
diastolic by 5 mmHg. Most importantly, BP continued to decrease as exercise training continued for an54 ñ HJC (Hellenic Journal of Cardiology)
other 16 weeks, allowing a 33% reduction in antihypertensive medication for the entire group. BP in the
non-exercising group increased slightly during the
same period.
The findings of this study suggest that patients with
more severe stages of hypertension can safely tolerate
exercise of moderate intensity. Moreover, such exercise
as an adjunct to drug therapy can lead to a better management of high BP compared to the medication therapy alone and, in some cases, a reduction in the amount
of medications needed.43
Aerobic versus anaerobic exercise and blood pressure
Most interventional studies examined the efficacy of
aerobic exercise in lowering BP. Information regarding
the efficacy of strength training in BP control is limited.
This is in part due to the fact that the first studies of resistance training reported a dangerously high BP during
maximum effort. More specifically, in two studies the
mean peak pressure during the double leg-press for the
group reached 320/250 mmHg in individuals with normal BP at rest, with pressures in one subject exceeding
480/350 mmHg.44 Peak pressures with the single-arm
curl exercise reached a mean group value of 255/190
mmHg when repetitions were continued until failure.
In mildly hypertensive individuals, BP reached 345/245
mmHg during squatting.45 In these studies the enormous increase in BP can be attributed to the lifting of a
heavy weight to exhaustion and to the effect of the Valsalva maneuver.44,45
However, the increased interest in resistance training because of its potential preventive and therapeutic
qualities in relation to osteoporosis has led to a reexamination of the effect of resistance training on BP. Newer
studies did not observe the tremendous increase in
BP reported by previous studies, partly by avoiding
the Valsalva effect.44,45 However, their findings regarding BP reduction are inconsistent. Some suggested a
possible antihypertensive effect of strength training,
whereas others found none.30,46-49 In two of the studies
a small (5 mmHg), but significant reduction was observed in diastolic BP.46,47 In a third study the reduction
of 7 mmHg for systolic and 6 mmHg for diastolic BP
was comparable to the reduction in BP observed in the
control group.30 No changes in BP were noticed after 6
months of strength training in a group of 70-79 year old
men and women, or in a group of previously sedentary
middle-aged men after 20 weeks of strength training.48,49 A recent meta-analysis concluded that the reduction in BP as a result of resistance training is ap-
Physical Activity and Hypertension
proximately 3 mmHg.50 Based on these data, the American College of Sports Medicine concluded that studies
have not been consistent in demonstrating that strength
training lowers BP in hypertensive individuals. Accordingly, the American College of Sports Medicine, the
European Society of Hypertension, and the European
Society of Cardiology recommend that the primary type
of exercise for the management of BP should be aerobic, supplemented by resistance training. High intensity
isometric exercise, such as heavy weightlifting, should
be avoided.35,51
Physical activity and left ventricular hypertrophy
Left ventricular hypertrophy (LVH), known to be more
prevalent in hypertensive individuals, is considered to
be an independent risk factor for cardiovascular disease.52 The risk of cardiovascular morbid events, including sudden cardiac death, increases threefold in patients with LVH. 52
Epidemiological evidence suggests that physical activity has the potential to reduce left ventricular mass
(LVM). A 12% reduction in LVM index was noticed in
hypertensive individuals after 16 weeks of training.43 Interestingly, the amount of the reduction was similar to
the reduction achieved by medication therapy.53
Whether this exercise-related left ventricular mass
reduction has an effect in lowering the risk of mortality
in individuals with LVH has not been extensively studied. However, in a recent study, Rodriguez et al provided evidence that physical activity has a protective role
against the elevated risk of stroke associated with increased LVM.54 In this study, the risk of stroke was similar between physically active individuals with LVH and
those with normal LVM, leading to the conclusion that
increased physical activity may have the potential to reduce the elevated risk of cardiovascular events associated with LVH. 52
Blood pressure response during exercise
A progressive rise in systolic BP is observed during exercise as the workload increases, while diastolic BP remains near resting levels and may even decrease slightly. At peak exercise systolic BP reaches approximately
200 mmHg. However, in some individuals, systolic BP
rises substantially higher than 200 mmHg. This is referred to as an exaggerated BP response. Although a
definitive abnormal rise threshold has not yet been established, systolic BP >200 mmHg and/or diastolic BP
>110 mmHg at peak or near peak exercise has been
linked to future hypertension, heart disease and cardiovascular mortality.55-58 However, others found no
relationship.59-60
The potentially detrimental exaggerated BP response during physical activity can be attenuated by
moderate aerobic exercise training. Findings suggest
that higher fitness levels, as indicated by peak exercise
time, are inversely associated with BP at six minutes of
exercise. In both normotensive and hypertensive middle-aged women peak exercise time was the strongest
predictor of systolic BP response at six minutes of exercise.22
Lower exercise BP has also been reported in postmenopausal women following eight weeks of aerobic
exercise training.61 We also reported a significant reduction of approximately 20-27 mmHg in systolic and
10-14 mmHg in diastolic BP levels at maximal and submaximal workloads in hypertensive patients following
16 weeks of aerobic training. In addition, the rate-pressure product was significantly lower at sub-maximal and
peak workloads, suggesting that myocardial oxygen
consumption was lower at each workload. A notable
observation is that the peak workload following 16
weeks of training was significantly higher. Yet peak exercise BP was lower by 20 mmHg at virtually the same
peak heart rate. This suggests that the mechanism responsible for the lower BP was a reduction in peripheral resistance.62
Prehypertension and left ventricular hypertrophy
In 2003 the seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high BP (JNC 7) introduced a new category referred to as prehypertension, defined as systolic BP levels of 120-139 mmHg and/or diastolic BP levels of 80-89
mmHg.10 Prehypertensive individuals are at 1.5- to 2fold higher risk for developing hypertension and major
cardiovascular disease compared to those with normal
BP.13,52,63,64
The mechanisms involved in the increased risk
are not well defined. Prehypertension may mark the
beginning of a progressive increase in LVM and a
decline in cardiac function that remain undetected
for years. The findings of a recent study suggest that
the development of LVH starts in prehypertension.
In a group of 790 men and women with prehypertension, over 26% of the prehypertensive individuals
had LVH, compared with 3% of those with BP <120/
80 mmHg.65 In another study, the prevalence of LVH
in prehypertensive individuals was 11.4%.66 Howev(Hellenic Journal of Cardiology) HJC ñ 55
P.F. Kokkinos et al
er, the average age in this population was about half
the average age of the first mentioned study (26.8 versus 52 years).
The factors that influence the early increase in
LVM are also not well defined. However, we reported that the prevalence of LVH was significantly higher in low-fitness than in moderate and high-fitness individuals (48.3% versus 18.7% versus 21.6%, respectively).65 The investigators also reported that the strongest predictors of LVH were the exercise systolic BP
at five METs and the change in BP from rest to the
workload of five METs. In addition, they identified
that a systolic BP of 150 mmHg at the exercise level
of five METs was the threshold for LVH (sensitivity
86%, specificity 94%). The likelihood of LVH increased 4-fold for every 10 mmHg increment in systolic BP
beyond this threshold. There was also a 42% reduction in the risk for LVH for every one MET increase
in the workload.
Since previous reports suggest that high-fitness
individuals exhibit a lower exercise BP, the investigators examined the fitness status of the individual and
its association with exercise BP and LVH. 22 When
compared to high-fitness, individuals in the low-fitness category exhibited the following: 1) higher exercise BP at sub-maximal workloads; 2) greater prevalence of exercise BP above the threshold of 150 mmHg;
3) higher daytime BP;36 and 4) higher prevalence of
LVH.
Since the exercise workload of approximately 5
METs is similar to the workload of routine daily activities37 and the exercise BP during this workload is
very similar to the daytime BP, these findings suggest
that low-fitness individuals exhibit higher BP during
normal daily activities when compared to moderate
and high-fitness individuals.36 The increased hemodynamic load results in a higher myocardial workload, providing a stimulus for myocardial structural
changes.
Antihypertensive mechanisms of exercise
The underlying mechanisms responsible for the reduction in BP elicited by exercise training remain elusive and controversial. The prevailing current opinion
is that exercise training must act upon a number of
mechanisms, resulting in the reduction of total peripheral resistance, cardiac output, or both. It is generally agreed that the changes in BP are independent
of changes in body weight, body composition and dietary influences.52
Reductions in cardiac output, sympathetic nerve
activity, plasma norepinephrine levels, and total peripheral resistance have been reported.62,67,68 In a recent
meta-analysis involving 72 trials, 105 study groups, and
3936 participants, the authors reported reductions in
systemic vascular resistance, plasma norepinephrine,
and plasma renin activity as the main reasons for the
decrease in BP following exercise.26 In the past two
decades, several studies have shown that endothelial
function is impaired in hypertensive patients.69,70 Improved endothelial function is another possible mediator of the hypotensive response observed with exercise
training.71,72 An improvement in reactive hyperemia
following exercise has been demonstrated in hypertensive patients.73
Current recommendations
Both the American College of Sports Medicine and
the European Society of Hypertension recommend
physical exercise as a part of lifestyle modifications
in the prevention and treatment of hypertension.35,51
The specific recommendations are shown in Table 2.
The extent of pre-training evaluation of the cardiovascular status must depend on the intensity of the
exercise program and on the patient’s symptoms and
signs, total cardiovascular risk and presence of comorbidities.35,51 A symptom-limited exercise tread-
Table 2. Recommendations of the American College of Sports Medicine and the European Society of Hypertension concerning physical
exercise for the prevention and treatment of hypertension.
Frequency
Most, preferably all, days of the week.
Intensity
Moderate intensity (60-85% of predicted maximal heart rate or 40% to <60% of VO2 reserve*).
Time
≥30 min of continuous or accumulated physical activity per day.
Type
Primarily endurance physical activity supplemented by resistance training.
*VO2 reserve refers to the peak or maximal oxygen consumption (ml of O2/kg/min) minus resting consumption (3.5 ml/kg/min)
56 ñ HJC (Hellenic Journal of Cardiology)
Physical Activity and Hypertension
mill test may be warranted, especially for men over 45
years old and women over 55 years who are planning
an intense exercise program.35,51
Conclusions
It is now well accepted that increased physical activity
of appropriate intensity and duration is associated
with a reduced incidence of hypertension.23-25 Thus,
for primary prevention of hypertension an appropriate recommendation for a public health policy should
include the implementation of a low to moderate intensity exercise program most, preferably all, days of
the week.35
Recent data suggest that structural and functional
changes in the heart occur much earlier that first
thought. Over 26% of pre-hypertensive individuals
have LVH. The stimulus for the changes in the left ventricle appears to be an increased daily hemodynamic
load resulting from relatively high BP levels during routine daily activities. This increased workload provides
the stimulus for increases in LVM. The relatively high
exercise BP, daytime BP, and LVM observed in low-fitness compared to moderate and high-fitness individuals
suggests that low-fitness individuals exhibit higher BP
during routine daily activities. Conversely, increased
physical activity is associated with lower exercise BP at
submaximal workloads. This suggests that increased
physical activity consisting of daily brisk walks of 30-40
minutes in duration can lower BP and prevent the development of LVH.36,65
The predicted reductions in mortality from stroke,
CHD and all causes are substantial, even with modest
reductions in systolic BP in the entire hypertensive population.12 For individuals who are already hypertensive,
the implementation of regular exercise, alone or as an
adjunct to medical therapy, can improve BP control at
relatively lower doses of antihypertensive pharmacological agents, and reduce adverse events. The intensity of
exercise required can easily be achieved by middle aged
hypertensive individuals.35,43
References
1. Freis ED. Historical Development of Antihypertensive
Treatment. In: Laragh JH, Brenner BM, editors. Hypertension: Pathophysiology, Diagnosis, and Management. 2nd ed.
New York: Raven Press; 1995. p. 2741-2751.
2. Freis ED. Treatment of hypertension with chlorothiazide. J
Am Med Assoc. 1959; 169: 105-108.
3. Freis ED. Essential hypertension. Heart Bull. 1959; 8: 52-54.
4. Freis ED. The value of antihypertensive therapy. Bull N Y
Acad Med. 1969; 45: 951-962.
5. Freis ED. The Veterans Administration cooperative study on
antihypertensive agents: Implications for stroke prevention.
Stroke. 1974; 5: 76-77.
6. Freis ED, Wanko A, Wilson IM, Parrish AE. Treatment of
essential hypertension with chlorothiazide (diuril); its use
alone and combined with other antihypertensive agents. J
Am Med Assoc. 1958; 166: 137-140.
7. Poblete PF, Kyle MC, Pipberger HV, Freis ED. Effect of
treatment on morbidity in hypertension. Veterans Administration Cooperative Study on Antihypertensive Agents. Effect on the electrocardiogram. Circulation. 1973; 48: 481490.
8. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke,
and coronary heart disease. Part 1, Prolonged differences in
blood pressure: prospective observational studies corrected
for the regression dilution bias. Lancet. 1990; 335: 765-774.
9. Stamler J, Stamler R, Neaton JD. Blood pressure, systolic
and diastolic, and cardiovascular risks. US population data.
Arch Intern Med. 1993; 153: 598-615.
10. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the
JNC 7 report. JAMA. 2003; 289: 2560-2572.
11. The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med. 1997; 157: 2413-2446.
12. National High Blood Pressure Education Program Working
Group report on primary prevention of hypertension. 1993.
Arch Intern Med. 1993; 153: 186-208.
13. Vasan RS, Larson MG, Leip EP, Kannel WB, Levy D.
Assessment of frequency of progression to hypertension in
non-hypertensive participants in the Framingham Heart
Study: a cohort study. Lancet. 2001; 358: 1682-1686.
14. World Health Report 2002. Reducing risks, promoting
healthy life.
15. Rosamond W, Flegal K, Friday G, et al. Heart disease and
stroke statistics—2007 update: a report from the American
Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Circulation. 2007; 115: e69-171.
16. Vasan R, Beiser A, Seshadri S, et al. Residual lifetime risk
for developing hypertension in middle-aged women and men:
The Framingham Heart Study. JAMA. 2002; 287: 1003-1010.
17. Kokkinos PF, Narayan P, Papademetriou V. Exercise as hypertension therapy. Cardiol Clin. 2001; 19: 507-516.
18. Gibbons LW, Blair SN, Cooper KH, Smith M. Association
between coronary heart disease risk factors and physical fitness in healthy adult women. Circulation. 1983; 67: 977-983.
19. Palatini P, Graniero G, Mormino P, et al. Relation between
physical training and ambulatory blood pressure in stage I hypertensive subjects. Results of the HARVEST Trial. Hypertension and Ambulatory Recording Venetia Study. Circulation. 1994; 90: 2870-2876.
20. Reaven PD, Barrett-Connor E, Edelstein S. Relation between leisure-time physical activity and blood pressure in older women. Circulation. 1991; 83: 559-565.
21. Staessen JA, Fagard R, Amery A. Life style as a determinant
of blood pressure in the general population. Am J Hypertens.
1994; 7: 685-694.
22. Kokkinos PF, Holland JC, Pittaras AE, Narayan P, Dotson
CO, Papademetriou V. Cardiorespiratory fitness and coronary heart disease risk factor association in women. J Am
Coll Cardiol. 1995; 26: 358-364.
23. Blair SN, Goodyear NN, Gibbons LW, Cooper KH. Physical
(Hellenic Journal of Cardiology) HJC ñ 57
P.F. Kokkinos et al
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
fitness and incidence of hypertension in healthy normotensive men and women. JAMA. 1984; 252: 487-490.
Haapanen N, Miilupanlo S, Vuory I, Oja P, Pasanen P. Association of leisure time physical activity with the risk of coronary heart disease, hypertension and diabetes in middle-aged
men and women. Int J Epidemiol. 1997; 26: 739-747.
Paffenbarger RS, Wing Al, Hyde RT, Jung DL. Physical activity and incidence of hypertension in college alumni. Am J
Epidemiol. 1983; 117: 245-257.
Cornelissen VA, Fagard RH. Effects of endurance training on
blood pressure, blood pressure-regulating mechanisms, and
cardiovascular risk factors. Hypertension. 2005; 46: 667-675.
Seals DR, Silverman HG, Reiling MJ, Davy KP. Effect of
regular aerobic exercise on elevated blood pressure in postmenopausal women. Am J Cardiol. 1997; 80: 49-55.
Somers VK, Conway J, Johnston J, Sleight P. Effects of endurance training on baroreflex sensitivity and blood pressure
in borderline hypertension. Lancet. 1991; 337: 1363-1368.
Zanettini R, Bettega D, Agostoni O, et al. Exercise training
in mild hypertension: effects on blood pressure, left ventricular mass and coagulation factor VII and fibrinogen. Cardiology. 1997; 88: 468-473.
Blumenthal JA, Siegel WC, Appelbaum M. Failure of exercise to reduce blood pressure in patients with mild hypertension. Results of a randomized controlled trial. JAMA. 1991;
266: 2098-2104.
Cooper AR, Moore LA, McKenna J, Riddoch CJ. What is
the magnitude of blood pressure response to a programme of
moderate intensity exercise? Randomised controlled trial
among sedentary adults with unmedicated hypertension. Br J
Gen Pract. 2000; 50: 958-962.
Cox KL, Puddey IB, Morton AR, et al. Exercise and weight
control in sedentary overweight men: effects on clinic and
ambulatory blood pressure. J Hypertens. 1996; 14: 779-790.
Jessup JV, Lowenthan DT, Pollock ML, Turner T. The effects of endurance exercise training on ambulatory blood
pressure in normotensive older adults. Geriatr Nephrol Urol.
1998; 8: 103-109.
Marceau M, Kouame N, Lacourciere Y, Cleroux J. Effects of
different training intensities on 24-hour blood pressure in hypertensive subjects. Circulation. 1993; 88: 2803-2811.
Pescatello LS, Franklin BA, Fagard R, Farqular WB, Kelley
GA, Ray CA. American College of Sports Medicine position
stand. Exercise and hypertension. Med Sci Sports Exerc.
2004; 36: 533-553.
Kokkinos P, Pittaras A, Manolis A, et al. Exercise capacity
and 24-h blood pressure in prehypertensive men and women.
Am J Hypertens. 2006; 19: 251-258.
Kokkinos PF, Papademetriou V. Exercise and hypertension.
Coron Artery Dis. 2000; 11: 99-102.
Matsusaki M, Ikeda M, Tashiro E, et al. Influence of workload on the antihypertensive effect of exercise. Clin Exp
Pharmacol Physiol. 1992; 19: 471-479.
Motoyama M, Sunami Y, Kinoshita F, et al. Blood pressure
lowering effect of low intensity aerobic training in elderly hypertensive patients. Med Sci Sports Exerc. 1998; 30: 818-823.
Hagberg JM, Montain SJ, Martin WH 3rd, Ehsani AA. Effect of exercise training in 60- to 69-year-old persons with essential hypertension. Am J Cardiol. 1989; 64: 348-353.
Pescatello LS, Fargo AE, Leach CN Jr, Scherzer HH. Shortterm effect of dynamic exercise on arterial blood pressure.
Circulation. 1991; 83: 1557-1561.
Borhani NO. Significance of physical activity for prevention
58 ñ HJC (Hellenic Journal of Cardiology)
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
and control of hypertension. J Hum Hypertens. 1996; 10
(Suppl 2): S7-11.
Kokkinos PF, Narayan P, Colleran JA, et al. Effects of regular exercise on blood pressure and left ventricular hypertrophy in African-American men with severe hypertension. N
Engl J Med. 1995; 333: 1462-1467.
MacDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR.
Arterial blood pressure response to heavy resistance exercise.
J Appl Physiol. 1985; 58: 785-790.
Palatini P, Mos L, Munari L, et al. Blood pressure changes
during heavy-resistance exercise. J Hypertens Suppl. 1989; 7:
S72-73.
Harris KA, Holly RG. Physiological response to circuit
weight training in borderline hypertensive subjects. Med Sci
Sports Exerc. 1987; 19: 246-252.
Hurley BF, Hagberg JM, Goldberg AP, et al. Resistive training can reduce coronary risk factors without altering
VO2max or percent body fat. Med Sci Sports Exerc. 1988; 20:
150-154.
Cononie CC, Graves JE, Pollock ML, Phillips MI, Sumners
C, Hagberg JM. Effect of exercise training on blood pressure
in 70- to 79-yr-old men and women. Med Sci Sports Exerc.
1991; 23: 505-511.
Smutok MA, Reece C, Kokkinos PF, et al. Aerobic versus
strength training for risk factor intervention in middle-aged
men at high risk for coronary heart disease. Metabolism.
1993; 42: 177-184.
Kelley GA, Kelley KA, Tran ZV. Aerobic exercise and resting blood pressure: a meta-analytic review of randomized,
controlled trials. Prev Cardiol. 2001; 4: 73-80.
Mancia G, De Backer G, Dominiczak A, et al. 2007 European Guidelines for the management of arterial hypertension. Eur Heart J. 2007; 28: 1462-1536.
Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP.
Prognostic implications of echocardiographically determined
left ventricular mass in the Framingham Heart Study. N Engl
J Med. 1990; 322: 1561-1566.
Dahlof B, Pennert K, Hansson L. Reversal of left ventricular
hypertrophy in hypertensive patients. A metaanalysis of 109
treatment studies. Am J Hypertens. 1992; 5: 95-110.
Rodriguez CJ, Sacco RL, Sciacca RR, Boden-Albala B,
Homma S, DiTullio MR. Physical activity attenuates the effect of increased left ventricular mass on the risk of ischemic
stroke: The Northern Manhattan Stroke Study. J Am Coll
Cardiol. 2002; 39: 1482-1488.
Miyai N, Arita M, Miyashita K, Morioka I, Shiraishi T,
Nishio I. Blood pressure response to heart rate during exercise test and risk of future hypertension. Hypertension. 2002;
39: 761-766.
Singh JP, Larson MG, Manolio TA, et al. Blood pressure response during treadmill testing as a risk factor for new-onset
hypertension. The Framingham heart study. Circulation.
1999; 99: 1831-1836.
Filipovsky J, Ducimetiere P, Safar ME. Prognostic significance of exercise blood pressure and heart rate in middleaged men. Hypertension. 1992; 20: 333-339.
Mundal R, Kjeldsen SE, Sandvik L, Erikssen G, Thaulow E,
Erikssen J. Exercise blood pressure predicts cardiovascular
mortality in middle-aged men. Hypertension. 1994; 24: 56-62.
Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measurements at rest and during
exercise in hypertensive men. Hypertension. 1996; 28: 31-36.
Manolio TA, Burke GL, Savage PJ, Sidney S, Gardin JM,
Physical Activity and Hypertension
61.
62.
63.
64.
65.
66.
Oberman A. Exercise blood pressure response and 5-year
risk of elevated blood pressure in a cohort of young adults:
the CARDIA study. Am J Hypertens. 1994; 7: 234-241.
Seals DR, Reiling MJ. Effect of regular exercise on 24-hour
arterial pressure in older hypertensive humans. Hypertension. 1991; 18: 583-592.
Kokkinos PF, Narayan P, Fletcher RD, Tsagadopoulos D,
Papademetriou V. Effects of aerobic training on exaggerated
blood pressure response to exercise in African-Americans with
severe systemic hypertension treated with indapamide +/- verapamil +/- enalapril. Am J Cardiol. 1997; 79: 1424-1426.
Liszka HA, Mainous AG 3rd, King DE, Everett CJ, Egan
BM. Prehypertension and cardiovascular morbidity. Ann
Fam Med. 2005; 3: 294-299.
Qureshi AI, Suri MF, Kirmani JF, Divani AA. Prevalence
and trends of prehypertension and hypertension in United
States: National Health and Nutrition Examination Surveys
1976 to 2000. Med Sci Monit. 2005; 11: CR403-409.
Kokkinos PF, Pittaras A, Narayan P, Faselis C, Singh S,
Manolis A. Exercise capacity and blood pressure associations
with left ventricular mass in prehypertensive individuals.
Hypertension. 2007; 49: 55-61.
Drukteinis JS, Roman MJ, Fabsitz RR, et al. Cardiac and systemic hemodynamic characteristics of hypertension and prehypertension in adolescents and young adults: the Strong
Heart Study. Circulation. 2007; 115: 221-227.
67. Cleroux J, Kouame N, Nadeau A, Coulombe D, Lacourciere
Y. Aftereffects of exercise on regional and systemic hemodynamics in hypertension. Hypertension. 1992; 19: 183-191.
68. Floras JS, Sinkey CA, Aylward PE, Seals DR, Thoren PN,
Mark AL. Postexercise hypotension and sympathoinhibition
in borderline hypertensive men. Hypertension. 1989; 14: 2835.
69. Linder L, Kiowski W, Buhler FR, Luscher TF. Indirect evidence for release of endothelium-derived relaxing factor in
human forearm circulation in vivo. Blunted response in essential hypertension. Circulation. 1990; 81: 1762-1767.
70. Panza JA, Quyyumi AA, Brush JE, Epstein SE. Abnormal
endothelium-dependent vascular relaxation in patients with
essential hypertension. N Engl J Med. 1990; 323: 22-27.
71. DeSouza CA, Shapiro LF, Clevenger CM, et al. Regular aerobic exercise prevents and restores age-related declines in endothelium-dependent vasodilation in healthy men. Circulation. 2000; 102: 1351-1357.
72. Higashi Y, Sasaki S, Kurisu S, et al. Regular aerobic exercise augments endothelium-dependent vascular relaxation
in normotensive as well as hypertensive subjects: role of endothelium-derived nitric oxide. Circulation. 1999; 100: 11941202.
73. Higashi Y, Sasaki S, Sasaki N, et al. Daily aerobic exercise
improves reactive hyperemia in patients with essential hypertension. Hypertension. 1999; 33: 591-597.
(Hellenic Journal of Cardiology) HJC ñ 59